INSURANCE / TAKAFUL DISPUTE

INFORMATION TO COMPLAINANT

1. PROCEDURE ON LODGING A DISPUTE

Before you lodge a dispute with the Ombudsman for Financial Services (OFS), you must first refer your
dispute to the Financial Service Provider (FSP) concerned, who is a Member of the Financial Ombudsman
Scheme (FOS) with a view to finding an amicable settlement.

2. TIME LIMIT FOR LODGING A DISPUTE

(1) You may refer your dispute to the OFS:

(a) within 6 months from the date of the final decision by the FSP concerned; or
(b) after 60 calendar days from the date of your dispute was first referred to the FSP concerned in
respect of which no response has been received from that FSP.
(2) For more information on the type of disputes that can be referred to the OFS, you can refer to the
website at www.ofs.org.my.

3. ELIGIBLITY TO LODGE A DISPUTE

Eligible Complainant
You may bring a dispute to the OFS if you are –
(1) a financial consumer who uses or has used any financial services or products provided by the FSP –
(a) for personal, domestic or household purposes; or
(b) in connection with a small business*.
*small business refers to small and medium enterprises (SMEs) as defined in the “Guideline for
New SME Definition” issued by SME Corporation Malaysia in October 2013.
(2) a financial consumer includes:
(a) a person insured under a group policy or a person covered under a group takaful certificate
where the premiums or contributions are paid by the person insured or the person covered;
(b) a third party who is:
(i) an insurance or takaful claimant for motor third party property damage;
(ii) a nominee or a beneficiary under a life policy/family takaful certificate or a personal
accident policy/takaful certificate, including a beneficiary under a group policy or a
group takaful certificate where the premiums or contributions are paid by the person
insured or the person covered; and
(iii) a person insured under a group policy and his beneficiaries or a person covered under
a group takaful certificate and his beneficiaries, where the premiums or the
contributions are paid by the Federal and/or State Government and the group policy
or the group takaful certificate provides for the person insured or the person covered
to deal directly with the FSP in the event of a claim.
Eligible Disputes
Disputes which are related to direct financial loss falling within the following monetary limits:
(1) Insurance or takaful claims not exceeding RM250, 000.00; and
(2) Motor third party property damage claims not exceeding RM10, 000.00.

4. DISPUTES OUTSIDE THE SCOPE OF THE FINANCIAL OMBUDSMAN SCHEME

(1) A dispute that is beyond the monetary limit specified in Schedule 2 of the Terms of Reference (TOR) of
the OFS, save where mutually agreed in writing by the OFS, the Eligible Complainant and the FSP in
accordance with the TOR;

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 (2) A dispute on general pricing, product features, credit or underwriting decisions, or applications to
restructure or reschedule a loan or financing which are commercial decisions within the discretion of
the FSP;
(3) A dispute concerning the actuarial standards, tables and principles which the FSP applies to its long
term insurance/takaful business (including the method of calculation of surrender values, paid up
policy values and the bonus rate applicable to the policy in question) for insurance or takaful claims,
except guaranteed payments which are explicitly mentioned in the terms and conditions of the policy;
(4) A dispute relating to a contract of employment between the FSP and its officers and employees or
agency matters concerning the FSP;
(5) A dispute that has been filed in court or referred to arbitration or has been decided by a court or
arbitrator;
(6) A dispute that is referred to the FOS after more than six months from the date the FSP has provided its
final decision;
(7) A dispute that is time barred under the Limitation Act 1953 or Limitation Ordinance (Sabah) (Cap.72)
or Limitation Ordinance (Sarawak) (Cap. 49);
(8) A dispute that had been previously decided by the OFS (including a dispute decided under the
Predecessor Scheme) unless new evidence, which are material facts that could change the earlier
decision, is available for the OFS’ consideration;
(9) A dispute on investment performance of a financial product except in relation to non-disclosure of
facts or misrepresentation;
(10) A dispute on capital market services and products offered or marketed by the FSP;
(11) A dispute that involves more than one Eligible Complainant and has been referred to the FOS without
the consent of the other Eligible Complainant, and the OFS is of the view that it would be
inappropriate to deal with the dispute without that consent;
(12) A dispute involving claims arising from a third party bodily injury or death; and
(13) A dispute relating to the payment of policy moneys under a life policy and personal accident policy or
payment of takaful benefits under a family takaful certificate and personal accident takaful certificate
made in accordance with the provisions set out in Schedule 10 of the Financial Services Act 2013 and
the Islamic Financial Services Act 2013, respectively.

5. DISPUTES THAT MAY BE EXCLUDED BY THE OFS

(1) A dispute that is frivolous, vexatious or lacking in substance; or
(2) A dispute that relates to or has an element of fraud and is therefore more appropriate to be handled
by other relevant law enforcement agencies.

6. SUBMISSION OF DOCUMENTS
Please send the duly completed Insurance/Takaful Dispute Form together with other required documents
to:

By Post : By Walk-In:
The Chief Executive Officer Monday to Friday 08.30 – 13.00
Ombudsman for Financial Services 14.00 – 17.30
Level 14, Main Block (Closed on Saturday, Sunday and Public Holidays)
Menara Takaful Malaysia
No. 4 Jalan Sultan Sulaiman By Fax : 03-2272 1577
50000 Kuala Lumpur
By Email : enquiry@ofs.org.my

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BORANG PERTIKAIAN INSURANS/TAKAFUL
INSURANCE/TAKAFUL DISPUTE FORM

Perhatian/Notice:
 Borang ini perlu diisi dengan penuh. Jika perlu bantuan, hubungi kami (03-22722811).
This form must be fully completed. If you need assistance, please contact us (03-22722811).
 Sila tandakan () di mana berkenaan / Please tick () where applicable.

1. MAKLUMAT PEMEGANG POLISI/PESERTA / POLICYHOLDER/PARTICIPANT’S DETAILS

 Individu / Individual  Untuk Entiti Perniagaan Kecil / For Small Business

Entity:
 Keempunyaan Tunggal / Sole Proprietorship
 Perkongsian / Partnership
 Syarikat / Company
Nama Individu/Entiti Perniagaan Kecil / Name of Individual/Small Business Entity:

No. K.P. /No. Pasport/No. Pendaftaran Tarikh Lahir/Tarikh Pendaftaran Perniagaan atau
Perniagaan atau Syarikat / NRIC No./Passport Syarikat / Date of Birth/Business or Company
No./Business or Company Registration No.: Registration Date:

Pekerjaan/Profesion / Occupation/Profession: Alamat Surat Menyurat (sertakan poskod) /

Correspondence Address (include postcode):

Jantina / Gender:
 Lelaki / Male  Perempuan / Female

No. Telefon / Telephone No.:

Rumah / House:

Bimbit / Mobile:

Pejabat / Office: No. Faks / Fax No.:

E-Mel / E-Mail:

Hubungan dengan Penyedia Perkhidmatan Kewangan (PPK) / Relationship with Financial Service Provider
(FSP):

a)  Pengguna Perkhidmatan Kewangan untuk kegunaan persendirian atau domestik atau isi
rumah atau berkaitan dengan perniagaan kecil / Financial Consumer for personal,
domestic or household purposes; or in connection with a small business;
atau/or

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 b)  Pihak ketiga yang merupakan / Third parties who are:

 orang yang menuntut untuk kerosakan harta yang berpunca dari polisi motor
insurans atau takaful / claimant for motor third party property damage;
 penama atau benefisiari kepada pelanggan PPK / nominee or beneficiary to the
FSP’s customer
 orang yang diinsuranskan dan benefisiari orang yang diiinsuranskan di bawah
kumpulan insurans atau takaful berkelompok / person insured or covered and his
beneficiary under group insurance/takaful

2. MAKLUMAT PIHAK KETIGA/WAKIL PERNIAGAAN KECIL / THIRD PARTY/ SMALL BUSINESS

REPRESENTATIVE’S DETAILS
Nama / Name: No. K.P. /No. Pasport / NRIC No. /Passport No.:

Tarikh Lahir / Date of Birth:

Nama Jawatan (jika bagi pihak Entiti Perniagaan) / Jantina / Gender:

Job Title (if on behalf of Business Entity):  Lelaki / Male  Perempuan / Female

Pekerjaan/Profesion / Occupation/Profession:

No. Telefon / Telephone No.: Alamat Surat Menyurat (sertakan poskod) /

Correspondence Address (include postcode):
Rumah / House:

Bimbit / Mobile:

Pejabat /Office:
No. Faks / Fax No.:

E-Mel / E-Mail:

3. MAKLUMAT PENYEDIA PERKHIDMATAN KEWANGAN / FINANCIAL SERVICE PROVIDER’S DETAILS

Nama PPK / Name of FSP:

Kategori / Categories:

 Syarikat Insurans Berlesen / Licensed  Pengendali Takaful Berlesen / Licensed

Insurance Companies
 Broker Insurans yang Diluluskan / Approved
Insurance Brokers
 Penasihat Kewangan yang Diluluskan /
Approved Financial Advisers
Takaful Operators
 Broker Takaful yang Diluluskan / Approved
Takaful Brokers
 Penasihat Kewangan Islam yang diluluskan /
Approved Islamic Financial Advisers

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4. JENIS POLISI INSURAN/SIJIL TAKAFUL / TYPE OF INSURANCE POLICY/TAKAFUL CERTIFICATE

 Kecurian / Burglary  Motor / Motor

 Kebakaran / Fire  Gadai Janji / MRTA
 Perjalanan / Travel  Kemalangan Diri / Personal Accident
 Hayat atau Keluarga / Life or Family  Liabiliti Awam / Public Liability

 Hospital & Pembedahan / Hospitalisation  Empunya Rumah/Isi Rumah /

& Surgical Houseowner/Householder
 Lain-lain (sila nyatakan) / Others (please specify):

_______________________________________________________

5. BUTIRAN PERTIKAIAN / DISPUTE DETAILS

 Penolakan Tuntutan / Repudiation of  Tidak Berpuashati dengan Tawaran /

Claim Unsatisfactory Offer

 Lain-lain (sila nyatakan) / Others (please specify):

_______________________________________________________

No. Polisi Insuran/Sijil Takaful / Insurance No. Rujukan / Reference No.:

Policy/Takaful Certificate No.:

Tarikh Mula Polisi Insuran/Sijil Takaful / Tarikh Tamat Polisi Insuran/Sijil Takaful /
Policy/Certificate Commencement Date: Policy/Certificate Expiry Date:

Tarikh Kejadian / Date of Incident: Jumlah Diinsurankan/Dilindungi / Amount

Insured/Covered:

RM ________________________

Jumlah Pertikaian / Amount Disputed:

RM ________________________

Matawang lain / Other Currency:

___________________________

*Nota: Jika jumlah dituntut adalah dalam matawang lain, OFS akan tukar jumlah dituntut dalam Ringgit
Malaysia. Kadar tukaran berdasarkan kadar akhir yang dipaparkan di laman web Bank Negara Malaysia
ketika tarikh kejadian. / Note if claim amount is quoted in a foreign currency, OFS will convert the amount
claimed in Malaysian Ringgit based on the conversion rate published on Central Bank of Malaysia’s
website as at the date of loss.

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6. PENERANGAN MENGENAI PERTIKAIAN / DESCRIPTION OF DISPUTE
Sila beri penerangan jelas mengenai pertikaian anda. Jika anda memerlukan lebih ruang, sila lampirkan
keterangan pertikaian di dalam kertas berasingan. Anda boleh lampirkan dokumen tambahan berkaitan
dengan pertikaian anda bersama-sama Borang ini. / Please provide a clear explanation on your dispute.
If more space is required, please attach the description of the dispute on a separate sheet of paper. You
may attach additional documents relevant to your dispute together with this Form.

Pertikaian saya/kami adalah seperti berikut / My/Our dispute is as follows:

7. TINDAKAN YANG DIAMBIL BERKENAAN DENGAN PERTIKAIAN ITU / ACTIONS TAKEN IN RESPECT OF
THE DISPUTE
Sudahkah anda menerima surat/e-mel keputusan muktamad PPK? Jika ya, sila tandakan () dan
nyatakan tarikh surat/e-mel keputusan muktamad. Jika tiada, nyatakan tarikh tuntutan bertulis dibuat
kepada PPK tersebut. / Have you received the FSP’s final decision letter/email? If yes, please tick () and
state the date of the final decision letter/email. If no, please state the date the claim was made in writing
to the FSP.

 Ya / Yes Tarikh keputusan muktamad / Date of final decision: ____________________

 Tidak / No Tarikh tuntutan kepada PPK / Date of claim to the FSP: ____________________

Adakah pertikaian anda telah difailkan di mahkamah atau dirujuk kepada penimbangtara? Jika ya, sila
tandakan () dan nyatakan tarikh tindakan difailkan. / Have your dispute been filed in court or referred
to arbitration? If yes, please tick () and state the date the dispute was filed.
 Ya / Yes Tarikh / Date : ______________________

No Rujukan / Reference No : ______________________

 Tidak / No

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8. SALINAN DOKUMEN DILAMPIRKAN / COPY OF DOCUMENTS ATTACHED
 Surat/e-mel keputusan muktamad PPK  Pengenalan Pemegang Polisi & Pengadu
(wajib) / Final decision letter/email from FSP (Kad Pengenalan/Pasport/Sijil SSM) /
(compulsory) Policyholder/Participant & Complainant’s
Identification (Identity Card/Passport/SSM
Atau / or
Certificate)
Surat/e-mel tuntutan kepada PPK  Jadual & Polisi Insuran/Jadual & Sijil Takaful
(sekiranya PPK tidak mengeluarkan / Schedule & Insurance Policy/Schedule &
keputusan muktamad selepas tempoh 60 Takaful Certificate
hari dari tarikh tuntutan/pertikaian pertama
 Pengesahan bertulis status Perniagaan Kecil
kali dikemukakan) / Claim/Dispute Letter to / Written confirmation Small Business status
the FSP (If the FSP has not issued a final
decision after 60 calendar days from the  Lain-lain (sila nyatakan jika berkaitan) /
date the claim/dispute was first referred) Others (please specify if relevant)
(compulsory)
___________________________________
 Laporan Perubatan / Medical Report

9. AKUAN DAN AKU-JANJI / DECLARATION AND UNDERTAKING

a. Saya/Kami, dengan ini mengaku bahawa, sepanjang pengetahuan saya/kami pertikaian
saya/kami bukan perkara yang tertakluk kepada prosiding mahkamah atau penimbangtara. /
I/We, hereby declare that, to the best of my/our knowledge my/our complaint is not the subject of
court or arbitration proceedings;
b. Saya/Kami berjanji untuk memaklumkan kepada OFS, sekiranya, selepas permohonan ini dibuat,
saya/kami telah membuat tuntutan dengan badan-badan lain, dan/atau memulakan prosiding
undang-undang, terhadap Anggota yang berkenaan dan/atau ejennya. / I/We undertake to
inform the OFS, if, after this application has been made, I/we have lodged a claim with other
bodies, and/or commenced legal proceedings, against the FSP concerned and/or their agents.

10. AKUAN DAN AKU-JANJI BAGI TUJUAN AKTA PERLINDUNGAN PERIBADI 2010 / DECLARATION &
UNDERTAKING FOR PURPOSES OF THE PDPA 2010
a. Saya/Kami bersetuju bahawa data peribadi saya/kami yang telah diberi secara sukarela dalam
borang ini adalah untuk tujuan pemprosesan pertikaian saya/kami seperti dinyatakan dalam
Terma-Terma Rujukan (TTR) OFS. Maklumat dan data peribadi yang disediakan akan diuruskan
oleh atau didedahkan hanya kepada kakitangan OFS atau sebagai mungkin diperlukan oleh mana-
mana undang-undang bertulis atau dengan perintah mahkamah. Saya/Kami faham bahawa
maklumat yang boleh digunakan untuk tujuan penyelidikan, penilaian dan pendidikan dengan
syarat OFS tidak akan menggunakan maklumat dalam cara yang mendedahkan atau mungkin
mendedahkan, secara langsung atau tidak langsung, pengenalan saya/kami. / I/We agree that the
personal data I/we have voluntarily provided in this form is for the purpose of processing my/our
dispute as set out in the OFS’ Terms of Reference (TOR). The information and personal data
provided will be handled by or revealed only to the personnel of the OFS or as may be required by
any written law or by order of a court of law. I/We understand that the information may be used
for research, evaluation and educational purposes, provided that the OFS shall not use any
information in a manner which reveals, or is likely to reveal, directly or indirectly, my/our identity.

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 b. Saya/Kami bersetuju bahawa OFS boleh meminta data peribadi saya/kami dan maklumat
berkaitan yang lain dan bahan-bahan dari PPK yang berkenaan, bagi tujuan pemprosesan
pertikaian saya/kami seperti yang dinyatakan dalam TTR OFS. Bagi mengelakkan keraguan, ini
membentuk persetujuan saya/kami berhubung dengan mana-mana pendedahan data peribadi
dan maklumat berkaitan yang lain dan bahan-bahan daripada PPK berkenaan. / I/We agree that
the OFS may request for my/our personal data and other relevant information and materials from
the FSP concerned, for the purpose of processing my/our dispute as set out in the OFS’ TOR. For
the avoidance of doubt, this constitutes my/our consent in respect of any disclosure of personal
data and other relevant information and materials from the FSP concerned.
c. Saya/Kami sedar bahawa saya/kami mempunyai hak untuk meminta akses dan membuat
pembetulan kepada data peribadi yang saya/kami kemukakan dalam borang ini. Permintaan
rasmi hendaklah dikemukakan secara bertulis kepada OFS. / I/We am/are aware that I/we have
the right to request access to and make correction of my/our personal data submitted in this
form. Formal requests should be submitted in writing to the OFS.
d. Saya/Kami bersetuju bahawa saya/kami telah membaca dan memahami syarat-syarat di atas, dan
bersetuju untuk pemprosesan pertikaian saya/kami mengikut proses penyelesaian pertikaian
yang dinyatakan dalam TTR OFS. Saya/Kami mengesahkan bahawa semua maklumat yang
diberikan dalam borang pertikaian ini adalah benar, lengkap dan tepat. / I/We agree that I/we
have read and understood the above terms, and consent to the OFS processing my/our dispute
according to the dispute resolution process set out in the OFS’ TOR. I/We confirm that all
information provided in this dispute form is true, complete and accurate.

11. TANDATANGAN / SIGNATURE

_________________________ _________________
Pemegang Polisi/Peserta Tarikh / Date
Policyholder/Participant

_________________________ __________________
Pihak Ketiga/Wakil Peniagaan Kecil Tarikh / Date
Third Party/Small Business Representative

12. UNTUK PENGADU YANG HADIR DI PEJABAT OFS / FOR WALK-IN COMPLAINANT AT OFS’ OFFICE
Diuruskan oleh / Attended to by:

__________________________________ _______________
(Nama kakitangan OFS / Name of the OFS staff) Tarikh /Date